follows up with that, in another year you are going to probably be gone into the administration. i hope not. i hope you all stay. are you laying in to process so whoever takes your place, assuming you're not brought back, that the transition would be seamless and the justification keeps going? >> we're absolutely looking at ways to[n@v institutionalize wh we're talking abouting doing. >> that's a better word. >> and i would say that one of the important roles this committee can play is to be a source of continuity about some of these operational concepts. >> i think you're right. >> as we bridge across administrations. >> so you've got, what, six or seven different outsourcing programs out there. one of them is project arch which has been successful in montana. had a few hiccups but not bad.

can you just give me a quick how that transitions for those folks once this plan is put in place? >> you're right. the project has been very successful. we took a lot of lessons as we built this plan. >> sure. >> there's a lot of lessons about preserving veterans' choice, the whole episode of care came from arch. a lot of lessons learned about how to work with community providers, how to make sure there's a direct connection between va and community providers and from the business side of really having one pot of money for care. >> sure. >> i think what we tried to do in the plan is create the eligibility criteria that focus into these three big buckets. one is geography, wait time and availability of services. so for the most part a lot of the veterans using it will be able to use community care through one of those three mechanisms. there may be some folks who would have to change providers. in those circumstances we want to create a transition plan to

make sure there's a warm handoff as needed. >> okay. that's good. what i just want to point out is actually the candidates' example, if you don't have people on the ground who know what you want, ain't going to happen. so i hope that communication filters all the way through middle management to the ground because you have some great folks on the ground. the last thing, if i might, mr. chairman, the last thing i'm going to say is that, sloan, you're right next to the big guy. we had a scheduling hearing here a month or two ago. on scheduling within the va. he said he's working -- they said the va is working on a new scheduling program. is that correct? >> yes. we are. >> how much is that baby going to cost? >> in fact, there are two or three efforts under way. we're going to in about six months, maybe less, to provide veterans the ability to schedule an appointment for primary care and mental health care.

>> that was an off the shelf program. >> through a mobile app. this was developed inside va. the other thing, the second leg of the effort is what we call scheduling enhancement where we've taken and modified -- actually put a graphical user interface on top of the old 1980s era scheduling system so it looks like a 21st century app and works like one. and that's happening within the next six months or so. the longer term scheduling process is this comprehensive replacement. we're going to do that in a very deliberate kind of way because we're about to deliver the field a substantial improvement in scheduling functionality. people in the field who have seen this working are awestruck. they can't believe we have something coming that soon. with the graphical user

interface. >> so let me just ask you this because the last and good people at the panel but didn't give me much hope. they said if i'm a veteran and it's the first of va and i schedule on the 20th there's no wait time. but if that -- if that appointment was delayed until the 25th of december, when it was supposed to be -- that's a five-day wait time. that's how it's valued. is that going to change because that's not real? >> let me tell you what's real. we want appointment scheduling to be clinically relevant or we want it relevant to the desires of the veteran. when you measure as the create date, if my doctor tells me i'm seeing my doctor for a chronic condition, i want to see you back in 90 days and we schedule an appointment in 90 days, did i wait 90 days for that appointment? it was scheduled coincident with

the clinically indicated date. if i call in and i say, i need to come see the doctor, see the dermatologist, but i'm going to be traveling for the next three weeks, when can i get in after that? and we schedule that veteran in 24 days, what's my wait time? did i wait 24 days for that appointment? so what we're trying to do here is make it either clinically relevant or relevant to when the veteran wanted to be seen. that's where we measure the wait time gap from. there is no relevance versus the create date. the large majority are returned to clinic appointments and so you would see consistently if you were looking at wait time data, examples of people waiting 120 days or people waiting 60 days or people waiting six months, 180 days for an appointment when, in fact, that's exactly when had he were supposed to come in and be seen.

>> you're right. except for the fact that i am sorry, mr. chairman, i went down this road, but how the hell do we measure wait times? because if i'm a veteran -- look, took my grand daughter to the emergency room the other day. everything worked out fine. i spent five hours in the emergency room. they looked at her for maybe 20 minutes of that five hours. i still spent five hours in the emergency room. >> right. >> when that person sets up an appointment, how are we to know which is which -- that person has a heart -- a pain in his heart and needs to get in today and was put off for three days? you're right, it's more kr critical. how are we going to know what's going on as an oversight committee? quite frankly why this is important, and i don't mean to be critical, what is important we had a real bad hearing here on phoenix a couple, few years ago. it was a horrible hearing. how are we going to know the

metrics? you can get back to me. tillis wants to ask some questions, too. how do we do any oversight? i got you. i understand. how do you get oversight on that? >> we check that every two weeks. >> we'll take this up off line. the truth is that it doesn't work so good, all right? thanks. i appreciate -- >> thank you, senator tester. >> -- your flexibility. >> senator tillis? >> i never get tired of hearing your questions. >> you haven't been here long enough. >> i want to shift gears to really get back to tap on what senator tester was getting at earlier in terms of institutionalizing this so we're not all after sudden restarting in 2017. said a couple of things that give me hope and give me concern and i'm coming from a systems

person that's helped large companies decomplex their environment. i like the idea of the graphical user. i use this as an example where it's a good short-term fix. on the other hand it adds another layer of complexity. i've implemented those systems. we used to call them lipstick on a pig. so what you've done is implemented something that makes it easier in the process of doing that you've probably not only aggregated data from other systems, you probably added data which adds another layer of complexity when you finally get to the ultimate task of replacing it. we have to be careful mott to go after short-term priorities that may be voiced from us or others at the expense of creating a long-term, sustainable, economically viable fix. that's more of a direction than i would think that you all would agree with that. i would be fascinated if any of you didn't. >> we agree wholeheartedly with you. >> one thing that i think we

need to do, i sometimes think we need to have hearings here where the only thing that is at the witness stand is a really big plate glass mirror. the cio is topnotch. has great experience, great relevant experience for the job she's been assigned. what you need to do as you go through these buy versus build decisions is make absolute ly certain that you're buying what creates a best practice and not necessarily creating a franken system where you start out and it looks great, but then you say this congressional mandate needs this reporting. this congressional mandate or this special project is requested by some senator requires so many variants that by the time you get finished what you bought bears no resemblance to the baseline project you want to maintain. we had a hearing where senator brown and i moved a bill that's

going to provide a benefit, and i think, sloan, you were in that hearing, where i said, it's a shame that a benefit that over ten years will equate to about $6.2 million is going to require $5.1 million in systems changes before you can start providing the benefit. we need to make sure you can come back. i want to associate myself with the comments made by most of the members and i share the frustration of senator sullivan. i will not get into the episodic issues with fayetteville or anything else in this hearing. that's why we'll have conversations outside of the hearing. but at some point there needs to be a cost associated with the shift of priority -- >> yes. >> -- that comes from the direction you're receiving from this committee. i will take at face value that the value provided to the states that you're prioritizing like senator sullivan's is worth it

over the distraction and the diversion of resources. but we have to start getting very serious and have everyone understand what the distraction possibly cost us in terms of shortening the time to ben pefi for the overall transformation. we also need you all very quickly to be able to articulate in a way that we can understand what the time limits that we have in the va committee why what i may be asking you to do may move us further to the right in getting the transformation done. and the way you're going to do that is to create a plan that we can communicate before this committee on a state-by-state basis what the footprint looks like, what is the mix of va, non-va choice, what is the time line of benefit? what are the things that we can expect on a fairly immediate basis so that each one of us can feel like we have that

information, and then we can determine whether or not it needs to be juggled or whether or not it's appropriate. we haven't had that. and i think that's one of the reasons why we get more of the episodic discussions that we have in a lot of these hearings, but i would encourage you very quickly. the list of legislative programs, it's disturbing that we will have to spend $300 million on a portal because these portals are fairly well established. i know we have a hairball of systems that we have to connect them to. that's where most of the costs come from. it's not the website, but it's disturbing to me that, again, if we do these short-term things, we're adding complexity and time to the long-term, integrated solution. and we have to reach a point where like all large-scale transformations there has to be a freeze but for emergencies so that you can start getting to work on what we're all wanting here sooner rather than later. i think you need to go back and

you need to take a more critical look at the things that you're having to accept as a given that congress has mandated that you believe no longer have a place in the transformed va. and it needs to go far beyond what you've probably thought about in terms of the enabling legislation for this particular program. if you don't do that, then you're building the transformed system on outdated policies that may or may not have ever been appropriate. they just happened to get through congress and you happen to live up to them because they've been mandated to you. i'm not going to get into a lot of questions except that the reason i continue to have this flavor to my discussion is i want to help you establish a plan that transcends your tenure and your positions. >> so do we. >> that continues to show progress as we get another president. i want to be an advocate for

that. it has to be articulated. and we need people in the va to put the mirror back on us, saying you're asking me to do something that's shifting me away from the other thing you asked me to do. if we do at that, and you put the mirror in, it's our problem. if we make a request, and you don't reflect back on us, it's your problem. and i want to make this our problem so that we can help facilitate the transformation. last things that i'll just mention, and we can speak first off, i appreciate the secretary and his staff for the update. i look forward to getting the information. thank you for that progress. it's important. i also want to reinforce what senator murray said. anytime i've heard it brought up. i've spoken with hundreds, probably at this point been in the presence of thousands of veterans over the last 11 months since i've been senator. i have yet to hear a single veteran who's received care from

the va say that they want purely a private choice. they want the optimum mix. they want veterans serving veterans. we want the best possible health care. we know we have world class practices out there. so we want to make sure that the people who come to us and say privatize it they almost all have one thing in common. they're not a veteran. and i want to listen to the veterans' voices and make sure we do a better job of providing the best care for them. which it includes choice. it includes non-va and includes it in different proportions based on the state. there are seven states who have one of the highest per capita ratio of veterans per population. i have a state that has more veterans than those states have total people. we all have unique needs, and we need to solve them. but i hope you all will go back and come back with a larger list of things saying that a part of the complexity is because you've told me to do things that are not best practice and not necessary for me to produce the

best clinical outcomes, so please relieve me of this burden. if you start doing that, your job's going to be a lot simpler, and what we do for the veterans is going to be a lot better. >> if i may, just 15 seconds. i can't tell you how much i appreciate that perspective, the willingness. i like to think that bob and i have done more of that kind of challenging over the last year and a half or so than has been done in a long time, but what you're describing is a real paradigm shift for the department, and it is an extraordinary opportunity, and we'll do our best to seize it. >> senator tillis, thank you for your commentary and analysis. very valuable. in the absence of the chairman, there is no second round, but i have a question. and it is in response, it's a question that follows, in fact, a question that you asked, i

think, secretary gibson of me. as i understand it, my take away from this hearing as far as the choice act is that it no longer matters. if you live within 40 miles of a facility that doesn't provide the service that you need, you qualify to have services at home? no. i thought that's what you said in response to chairman isakson. no, if you live within 25 miles of a cbac, it doesn't provide the service that you need, what happens? >> so first of all, the definition of cbac kind of going back, it has to be 25 miles from a facility or cbac that has a primary, that provides primary, care and mental health care. not the one off that has one doctor one day a week or something. if it's 25 miles from that you don't qualify under the geography criteria, however, you

might have a wait time for cardiology and you can access community care that way. that cbac may not refer folks to the local medical center for neurosurgery or ct surgery and all those services are provided in the community. i think a lot of times people get fixated on the geography. there's more than one way that people can access community c e care. some of that is through wait times or they just don't access that local referral in the cbac. >> so veterans than 40 miles to a cbac that has who live closer a full-time position have a different standard than those who live further than 40 miles, is that true? >> that's correct. >> so the veteran that lives 25 miles from the cbac who has a full-time physician, needs an optometrist, there is no optics at the cbac would be told to travel the 200 miles to wichita? >> that's what we've described in here, the nature of the

service that i read to the chairman. in the past, i think that's exactly what would often times happen. and what we're saying is we don't want that to happen. so it makes absolutely no sense for a veteran to drive 200 miles to get his eyes checked. that's the kind of care that we should be referring to the community under choice. but to be very clear, and i think you realize this. if the and apperture is opened all the way to where you can get the care, the cost goes through the roof. and we simply do not have the resources to be able to deliver that. that's why we're trying to do this in a very deliberate fashion. >> so your plan described to us today is intended to resolve those kind of issues? no? >> the way we resolve those issues is it allows the local provider if i zigs and the veteran to make that determines. so we have the national criteria

of geography, wait time, and availability of services, but there was this one thing passed by the hill that allows nuance. when i see patients, and i see that physical therapy, you should not be driving 200 miles to get pt after you just had a knee replacement, we can make that decision together and they can access community care. >> do you make that decision -- >> in the office. >> together today regardless of what happens with your plan for the future. that's already available to that veteran? >> it is now, based upon what we put in place effective yesterday. >> so today is a new day. >> it is a new day, yes. >> and many of the concerns and complaints that i've raised in a long period of time are resolved in your mind by what happened yesterday at the va. you asked me where, you indicate that where do i get my concern. emporia shouldn't qualify, and it does. it comes from case work. it's what you heard around the

table. it's people bringing us issues, and the veteran who lives 25 miles from the cbac who can't get his eye glasses adjusted can't do that and has to drive to wichita. and that's the norm of how we relate to veterans. i checked with my staff. just this week we've had ten new cases in kansas related to the choice act and the distance necessary to travel. it is an ongoing -- >> would you share those with us so that we can go do a deep dive and understand -- that's where we can help identify the defects in the system, to understand where things aren't working. it would be great. hugely helpful. >> if i could add one other thing, some of the 421 million requesting have to do with communication, education and training. there's a big chunk of that. we didn't talk about that today. but what you're experiencing and what we're getting is if that information flow doesn't occur at every level of the organization there's a problem.

that's some of the costs associated to the plan is to improve the communication channels. >> i've asked this question previously. i've learned it exists. there's something called an abandonment rate. and that is described to me as those who apply for choice and conclude it's not worth it. those you've even perhaps reached out to, and they actually make a request to use choice and conclude to walk away. that could be a good thing, because they want to use the va in its traditional sense. it could be a bad thing, because they've hit the brick wall. they've hit the bureaucracy. i'd like to know the abandonment rate. i understand that's a number that you keep. i have no standing to deny the senator another question. >> thank you. thank you, chairman moran. the caring community and generally non-va medical services involve payments.

and there have been various efforts over the years to make sure that those payments are validly made. the va authorized a recovery audit program in the 112th congress, i believe. and the inspector general, as you well know, recently found, i believe, $311 million for fy 2014 in quotes, improper payments for the non-va medical payment plan. i would like to know what progress there's been made in the recovery audit program. understand there is a request for proposal or that that program is in the works. could you update me? >> this recovery audit program i am not immediately familiar with. i'm familiar with the efforts that we're doing to expedite and improve the processes around

prompt payment. i know that some of the payments that were identified as improper payments within the community had to do with the fact that they were done under individual authorizations instead of being done under provider agreements, which is one of the reasons we're anxious to have provider authority. we'll get you some information on the recovery effort and because i am not conversant on that at all. >> i would appreciate you getting me any information you can and hopefully in the near future. >> i will do that, yes, sir. >> senator tillis? >> this time i won't do a speech. it's actually gone from 50,000 foot to the ground level. dr. yehia, you mentioned when we were talking about for doctors who may go into the choice program that if they're already certified to provide medicare or medicaid coverage that you

provide that doctor or provider an agreement to allow them to provide va care. what is that provider agreement like? >> so the way that it works right now is we have these contractors, health net and tri west. they're the ones that contract or work with the providers. the provider agreement is like two pages. it's actually a very simple process. if a veteran wants to, like i was describing, see someone in fayetteville, north carolina and they're not part of the network, it's the responsibility of our contractor to reach out to that provider. have them join the network. >> but it's not a two-page agreement with 75 attachments? >> no. it's a simple agreement. it has issues that relate to the ability to share medical information, things like that. >> do you have any idea what the rejection rates are on, acceptance or rejection rates are on these agreements?

>> i don't know. >> do you have any information on how well we're doing with reimbursements for people who come under that versus a medicare or medicaid provider in terms of timeline to reimbursement, those sorts of things? >> yeah. in the choice program through our contractors, they are close to 100% payment within 30 days. in the direct payment from va, not through, we are at 79% payment within 30 days. working on an upward trend to get that much better. >> and then the real question is, is the 79% relatively simple care versus complex care so you get an idea of the dollars outstanding, not just the -- >> no, our care in the community can be very complex care as well. and -- >> that's what i was referring to. so is there any potential 80/20

rule where 80% -- or the 21% that's outstanding is 80% of all the dollars outstanding? just curious. >> the common metric that they use is claims that are not clean claims. they don't distinguish them by clinical criteria. were they more complex or not. >> if i go out and talk to provideers who are getting into choice, they're no longer telling me it's very, very difficult to do, and they're not getting paid on a timely basis. >> providers sometimes don't differentiate choice from va. so you're going to hear both things. they should be getting their payments 100% of the time within 30 days through choice. >> and that's because it would be a non-va provider by contract and a choice provider by episode. >> exactly. >> right. >> thank you, mr. chair. >> you're welcome. >> gentlemen, thank you very much. second gibson, doctor, thank you.

i ask the next panel to join us at the table. we should be joined by mr. roscoe butler, the deputy director of the veterans affairs and rehabilitation division of the american legion. mr. darin selnick, senior advice -- senior veterans affair adviser for concerned veterans of america, mr. bill rausch for afghanistan veterans of america, mr. raymond kelley of national legislative services of the veterans of foreign wars. >> and while you're taking your seats, i want to apologize that i have another commitment. i didn't realize that this hearing would last as long as it has. and so i may have to depart before you're done with your testimony. if that happens, i apologize and i'll leave the hearing in your hands, mr. chairman.

>> you have no alternative. thank you, senator blumenthal. gentleman and ma'am, thank you for joining us. we'll begin -- i can't see the name tag, but i think it's mr. butler. please proceed. >> thank you, acting chairman moran. ranking member blumenthal and members of the committee, the american legion believes in a robust veterans health care system designed to treat those who have worn the uniform. however, in the best of circumstances, there are situations where the system cannot meet the needs of the veteran. and the veteran must seek care in the community. i am privileged to be here today and to speak on behalf of american legion, our national commander dale burnett and more than 2 million members in over 14,000 posts across the country that make up the backbone of the nation's largest wartime

veterans service association. the american legion recognizes that the choice program was an emergency measure to make health care accessible to veterans where va was struggling with delivering such care. in recognition of the needs of an integrate d system to delive non-va health care when needed, the american legion believes va needs to develop a well-tee fined and consistent non-va coordination program that has appropriate policies and procedures that includes a patient strategy and takes their unique illnesses and injuries as well as travel and distance into consideration. the va purchase care program dates back to 1945 when the chief medical director of the veterans administration implemented va's hometown program. general holley recognized that many hospital admissions of world war ii veterans could be

avoided by treating them before they needed hospitalization. as a result, general holly instituted a program for hometown medical and dental care at government expenses for veterans with service-connected ailments. under the hometown program, eligible veterans could be treated in their community by a doctor or dentist of their choice. fast forward 70 years. va's implemented a number of programs for non-va programs. at the request of congress. programs like fee basis, project arch, patient centered community care, and the veterans choice program were implemented to ensure eligible veterans could be referred outside the va for health care if needed. va states that their community care program would streamline the above programs by transitioning them no a single community health care program that is seamless and transparent to veterans.

while these goals sound positive, the american legion believes by resolution that a prime minister plan for non-va care must include the following elements. ensure all newspaper-va community care contract provides complete military cultural awareness and evidence-based training. provide all non-va providers with full access to va's computerized masht records system. ensure va continues to improve its non-va coordination through the coordination program office. ensure va provides collection of information into the veteran's medical record. ensure va develops a national tracking system to avoid local or national local contracts from lapsing. and an automated claims processing system that fully ought mates the authorization and payment process. we are pleased to see that va's plan incorporates many elements

of our resolution. if approved by congress, the plan would be rolled out using a three-phase approach. the plan would be implemented gradually, much like tri care by developing network and streamlining business processes. additionally va plans call for cultivating a provider network to serve veterans utilizing federal health care providers, academic affiliates, and community providers. the american legion believes va has not yet demonstrated it has the expertise or experience for large provider networks. so far this year it has relied on third party participants such va plans does not specify whether it would continue utilizing third-party contractors to fulfill this requirement if the plan is approved.

serious thought needs to be given to this. we have concerns about va's ability to implement the plan. va has attempted to roll out or has rolled out numerous projects in past years that require system technology and policy changes. va must guarantee congress, vsos and veterans that their community care plan will not result in similar failures like other projects such as corps fls, scheduling redesign, a veterans lifetime electronic health record, or the initial rollout of the choice program to name just a few. veterans are calling on va to get it right, and on their first attempt and not continually waste taxpayers' dollars. in summary, if va can address the american legion's concerns,

we are cautiously optimistic that va plans for moving forward may work and could represent an important step toward a truly integrated model for developing veterans health care within va and the community collectively. i thank the committee for their hard work and consideration for this legislation as well as your dedication for finding solutions for problems that stand in the way of delivery of veterans health care, and i'm happy to answer any questions. >> thank you very much. >> mr. selnick. >> thank you, chairman moran, ranking member blumenthal and members of the community. i appreciate the opportunity to testify at today's hearing be a the recent release of programs. in the interest of full disclosure, i am the commissioner. my testimony reflects cva and my own observations. cva agrees there needs to be one veterans choice program that

deals with root problems and is simple, effective and fiscally responsible. with a veteran in control of how, when and where they wish to be served. this has been a stated goal of the va. we laud the va in coming up with a plan for such a program, after careful review it is our opinion that this plan does not meet the criteria listed above. instead, it continues the va status quo, cherry picks the status assessment. the plan will fail, costing taxpayers billions. impact negatively on veterans health care. instead of a simple program, va has developed a grandiose plan. that does not deal with the challenges it faces nor is in line with the doctor's comments. it will provide services commonly found in the health care industry. the aim is expanding into areas it does not have expertise in. we identified five key flaws in the plan. first, implementation requires a high performing health care organization such as the

cleveland clinic, the hva is using an antiquated hmo staff model focussing on a high degree of control. as the independent assessment has stated solving these problems would demand far reaching and complex changes that when taken to go amounts no less into system wide reworking of vha. the number of issues vha currently faces appears overwhelming. vha's in the midst of a leadership crisis and vha health care systems are in danger of becoming obsolete. last year vha made 5 million appointments but only completed 55 million appointments. headlines such as lapses in care endangered patients and reports suggest vha is not up to the task. second, va has provided a concept plan that proposes lofty goals and operating principles. there's not ground in the reality of the way veterans access their care. vha is operating under the false premise it is the medical home for the veterans it serves while

providing only minority health care. as the individual assessment states, it ranges from 15% to 34% to laboratory services. third, va gives lip service to the independent assessment recommendations, findings and systems approach but cherry picks recommendations and ignores others. the va is focused on what is best for it instead of bracing operations and leadership reforms needed. fourth, veterans want real choice in private health care. according to an october 2015 poll 91% of veterans want more health care choices. instead, va takes greater control over veterans ineligibility and access. veterans would be eligible if they are more than 40 miles from a va desi ignatedesignated. their needed care is from a specialist. with wait times they are gaming the system by having undefined wait times and leaving it up to the va providetory decide the necessary clinical time frame.

accessing the high performance network is another example. va has undetermined referral process that could take months for each step. the first hurdle is the va network and the preferred standard tiers all controlled by va. fifth, the plan is extremely premature especially in light of the change, the charge congress gave the commission on care to examine how best to organize vha and deliver health care to veterans. va plan could short circuit this existing charge and be in conflict with care recommendations. to overcome the flaws and challenges in the va plan cva proposes the following three steps. one, va should focus on the short-term solution of consolidation. phase one of the plan which should be refined with the addition of implementation, evaluation, should be done in consultation with the commissioner on care. two, va should refine phases two and three of the program in consultation with the commission on care using an integrated system as approached with proper governance, operations and leader sh leadership reforms.

three, va should finalize phases two and three only after the commission on care provides its findings and recommendations to the president and congress. although attempt to go move too quickly on consolidating the care programs, you must break the cycle by having the right plan that focuses on the veterans first not the va. president theodore roosevelt said a man who was good enough to shed his blood for the country is good enough to be given a square deal afterwards. cva is committed to overcoming all obstacles. achieve the shared commitment to veterans. >> mr. selnick, thank you, mr. rausch. >> chairman moran, on behalf of iraq and afghanistan veterans of america and our 425,000 members and supporters thank you for the opportunity to share views with you today at the hearing consolidating non-va care programs. we are proud to have testified in front of the committee recommending the need for

veterans enrolled in va health care and we applaud congress for requiring va to put forward a plan for consolidation. we want to recognize senior leaders for acknowledging the need for consolidation and providing an approach and process inclusive, transparent, and veteran centric. last year, the act was being implemented, it became apparent that the new law was confusing and added to a series of previous plans. 43% of respondents stated the main reason for not utilizing choice was simply because they did not know how. while 28% of our members who utilized the program said their experience using choice was extremely negative. although necessary to address the access crisis at va revealed by the scandal in phoenix, the choice program quickly became an example of what was and what was not working for veterans, physicians

and va employees when it came to providing accessible, timely, and high quality care in the community. iava has conducted polls and focus groups to understand what was needed in order to have a successful consolidation of care in the community. we've attended over 25 formal meetings with other vsos and staff to share what our members are experiencing at the local level in terms of care in the community and have had dozens of informal calls and meetings to provide direct feedback from post 9/11 veterans. we brief any plan must be simple to understand. it must be consistent across the country and place the needs of veterans above all else. the plan put forward by va meets the above criteria and should be the framework for legislation and provide improved and seamless access to care for veterans.

despite the progress that's been made by congress and va, we have three main concerns. one, congress drafting and enacting the required legislation to effectively consolidate care, two, va's ability to effectively implement the new laws designed to designate and consolidate care, and three, a continued focus on access without outcome to veterans, we have seen provider whose have not historically served the veteran community. congress acted swiftly and put veterans first in the wake of the access crisis by passing the choice act and this committee has been a strong partner with iava as the program was being implemented. unfortunately, some members of congress continued to put forward incomplete one-off plans and legislation that did not include feedback for veterans, vsos or va. as they move forward to simplify a very confusing process for

veterans to consolidate care in the community, iava highly recommends congress uses va's framework and avoid proposals that are one of or misinformed. it was congress that added to the confusion and inefficiencies resulted in a need to consolidate care. we believe congress should be mindful of these lessons. learn from them and leverage the plan as framework for consolidation of care moving forward. our second concern centers around va's ability to effectively implement a plan to consolidate care across the enterprise that avoids many of the mistakes made in the implementation of choice and puts the veteran at the center of every discussion. of every decision. during a recent discussion with post-9/11 veterans, there seems to be significant inconsistencies across va, and although i've had some good experiences, there are too many who have had bad experiences. i couldn't agree with them any

more. in order to address these inconsistencies, iava recommends stakeholders to put the veterans first and change the culture of va across the country. given shortcomings on the implementation of choice and customer service generally, the va should also continue its efforts with my va and ensure employees are properly and consistently trained on any plan to consolidate care. finally iava encourages everyone -- congress, va and everyone to place importance on the quality of care veterans are receiving, especially, especially as new providers join networks in the community. we need to pay special attention to the care that veterans receive to ensure it's consistent with the high quality of care provided by va and that private providers are trained to treat veterans.

as community providers are increasingly called upon to serve this population a recent report suggests community providers might not be well equipped to meet the needs and their family for posttraumatic stress and other mental industries. in closing, iava would again like to thank this committee for your leadership and continued commitment to our entire community of veterans. it's a privilege to testify in front of this committee today and we reaffirm our commitment to you and working with all of congress. va and vso partners to ensure veterans have the access to the highest quality of care and that our country fulfills its say kret obligation to care for those who have truly born the battle.os@ there have been tragedies in the past. however, we believe there's a real opportunity, a real opportunity to transform the va for today's veterans through a one-team, one-fight approach. thank you, and i'd be happy to field any questions. >> mr. rausch, thank you very much.

mr. kelley? >> on behalf of the independent budget partners, thank you for the opportunity to testify today. the partners strongly believe veterans deserve accessible and veteran centric care. in most instances, va is the best and preferred option, but va cannot provide all services to all veterans in all locations at all times. that is why they must have other public health care systems to expand viable options. after months of working closely with va officials and other stakeholders we are pleased that many aspects of the va's plan are closely aligned with veteran health care reform framework. we support va's concept of consolidating va care into a single program that would combine the capabilities of va health care system with other public and private health care providers in the community wherever necessary. as part of the consolidation, several community care programs

would be allowed to sunset, while allowing these programs to sunset is a natural part of the program, allowing them to expire without knowing that the current plan can carry the case load is unacceptable. we cannot support an across the board co-payment for these services. the idea of charging veterans who are service-connected for care is unacceptable. in order to make sure that they access it appropriately, they suggest the establishment of a nurse advice line. while the partners agree they must do a better job of collecting third-party payments we adamantly oppose withholding health care for veterans for not providing private insurance. the va should consider ways to incentivize them to provide that information.

the iv's framework builds on va's progress by addressing barriers outside the va's plan limited scope. our four-pronged approach framework looks beyond the division between va care and community care to create a blend and seamless system that will restructure the veterans health care delivery system, redesign the system and the systems that facilitate access to health care, realign resources to reflect its mission and reform va's culture with workforce initiatives and accountability. similar to va's plan, the iv framework would combine the strengths and capabilities of va and other public and private providers, but be a managed care program provide rural and remote veterans with options of receiving coordinated care regardless of where they live. we recommend va move away from a single arbitrary access

standard. access to care would be clinically based decision made between veterans and his or her doctor or health care professional. once the clinical parameters are determined, veterans would be able determined, veterans would choose among options developed within the network to schedule appointments convenient to them. it calls for changes to va strategic capital investment plan or skip process by including public private partnership options and blended existing replacement options to better leverage federal and local resources. we call for the establishment of a veterans review process similar to the review to align va strategic mission with budget and operational plans and provide continuity of plan akrog all administrations. the framework would establish an independent audit of budgetary accounts to identify waste, fraud and abuse.

we call for strengthening the veteran experience office by combining its capabilities with the patient advocate program. veterans experience officers would advocate for the needs of individual veterans who encounter problems obtaining benefits and services. they would be responsible for ensuring the healthcare protected -- protected under the title 38 are enforced. our plan uses the same public and private resources as proposals provided -- that provide veterans with vouchers or insurance plans. our plan makes them complimentary instead of in competition with each other. which will be key to providing high qualify care with the most ease of access possible for veterans. mr. chairman, this concludes my testimony. d partners look forward to any questions you may have. >> senator blumenthal? >> thank you. i appreciate your courtesy in allowing me to ask a couple of brief questions first. let me ask you, your

recommendation is that the va should finalize its choice program, the long-term new veterans choice program only-; after the commission on care provides its findings and recommendations to the president and congress, and they have decided which recommendations are feasible and advisable. do you have a time frame as to when those recommendations will be made? >> as of right now, based on the legislation, we are due at the end of february. >> in february? >> that is as of right now, that's when we're due. >> and so you would advise waiting until sometime this spring or later when there is feedback from the president and congress before the va finalizes its choice program? >> yes. i think the va's plan has some merits to it but it has a lot of work that has to be flushed out. it's a concept plan. that can be done. once again, i'm speaking for

myself, not the commission or anything. personally, i feel that can be a more collaborative process. as part of that collaborative process, let's have a process where we have a really integrated systems approach where we come up with an overall comprehensive solution. the choice program is not a solution on its own. it has to be integrated with the rest of the healthcare system. so coming up with a program on your own, that may be in conflict with other recommendations, would just cause more confusion. >> i would just like to add, although we have differing views and opinions about this specific plan, i would challenge anyone to suggest that the process hasn't been collaborative. in contrast to say two years ago working with the va, i don't believe that this process would have taken place. and baseed off a lot of the discussion between members of this committee and senior officials a moment ago, it seems your experiences have changed

with va. i would just like to highlight as did i in my testimony the numer -- over -- it was almost daunting, frankly. so i would emphasize that it has been transparent, it has been collaborative and unprecedented in the federal government from our perspective. thank you. >> mr. blake? >> senator, in full disclosurdi it would be fair to say the commission on care, we met with their staff and it's understanding they are hoping to extent their charge until next summer, which would mean this discussion would be put off until june, july or august at the earliest. i think that would be an unfortunate occurrence for the va, because as most of us here have testified, this plan that the va put forward is a good idea. it's a very good concept for how healthcare should be delivered. if we put it off for another potentially 12 months, where will we be now? will that solve the problems we're trying to address? >> i share the concern about timing. i understand the point about collaboration. i'm heartened and encouraged by

the feeling that i think is generally shared among this panel that the process has been collaborative and to that end, i am going to invite, in fact request that the va react to some of the excellent ideas that have been suggested by this panel if they have haven't done so. i would ask that the va, who are still present, let the record show that all of the witnesses on the prior panel are still here and can hear me make this request. i would ask that they react to these proposals, because these ideas are very promising and important. and i think collaboration is the key word here. the vsos have been extraordinarily and profoundly important in this process. and i want to thank all of you, gentlemen and lady, for the excellent ideas that you have offered today and throughout

this process. those who are represented here and others who are not on this panel. so thank you very much. and i look forward to additional collaboration. i think that's the operative word. thank you. >> senator moran. >> thank you very much. i think it was mr. rausch had who had statistics about experiences with the choice program, access to care in communities. let me ask all of you, you are all involved in helping your members, helping veterans access care. what's been the experience with the choice act for each of you, each of your organizations' members? >> for the american legion, we have had experiences where veterans have had positive experiences as well as not so positive experiences. it all depends upon the type of relationship the va has within the community and with the health net. we're still getting calls where

even from veterans where their claims have been turned over to collection because they're not being processed and paid in a timely manner. when we get those type of issues and concerns, and we turn them over to our vso liaison and central office and after they check into that, then we get an affirmative answer as to what was the breakdown and an easy solution to fix it. but then the question then becomes, how come we -- why did we get to that point? how come it wasn't appropriately addressed in the beginning? >> for our members, it has been mostly a nightmare. the number one thing that they say is, literally, the few that have been able to get choices because they have had a congressman or senator interfere on their behalf. the common thing they say is, why does it take a senator or congressman to get some help? the whole process for our

members -- you can go online and see the facebook posts -- has just been a continually struggle and battle. one of the number one questions that we get is, you know, look, if i'm within 20 miles of a va hospital but the heart surgeon i need is 100 miles, why am i denied that choice? why can't i get the service within 40 miles? why does tri-care offer a simple system of specialty and primary care metrics and the va has this convoluted process? >> thank you, senator. to repeat those numbers, currently, from our most recent survey, 43% stated the main reason for not using it was for confusion. 28% said they had a negative experience. we have seen from our polling data, a lot are social media, we have seen it increase. generally it has been a negative experience. it has increased. you mentioned kansas. i spent time in fort leavenworth because i was assigned there by

choice. so i knew kansas fairly well. i was looking at a map recently that the tri-west had showed me today or last month, excuse me, versus a year ago, the providers and the network that they built in kansas has been tremendous. so what we have seen is not a linear increase but an exponentially increase in the number of providers, veterans who understand it better. the va, frankly who were probably the worst performing initially in understanding how to coordinate that care, they have improved significantly. so although it has been a challenge, we have seen it start to sort of steadily uptick, which is why we mentioned in our testimony that there's some really positive things and lessons learned from choice, but also some negative things we have learned. just on the broader concept of choice -- it was mentioned earlier about the different plans that have been floated. again, one of the reasons we support this framework and reject some of the other plans, there are certain plans that want to take as someone mentioned earlier primary care

out of the va. well, as someone who actually had my primary care health appointment this morning at the va -- i have choice, because i have private healthcare as well. that would be removing choice for me. so there are certain plans out there that actually don't reduce cesut of va.ly eliminate choice which is why we think this collaborative approach that's been taken is a great and cle clear -- >> thank you very much. i appreciate your patience in waiting for the opportunity to testify and to be here to answer questions, which gives me the opportunity to tell the va how appreciative i am of their patience in staying to listen to the testimony. >> i apologize for having to go to the floor and make a brief speech. i missed almost all of your testimony, which i apologize for. i have been reading through -- last night's testimony. i have a couple of quick questions. i know it has been a long time. i thank you for staying. i thank the va representatives for staying and listening as well.